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Vol. 39, No. 4, pp. 333339
c 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 

EHR Documentation
The Hype and the Hope for Improving
Nursing Satisfaction and Quality
Outcomes
Ann OBrien, RN, MSN; Charlotte Weaver, RN, PhD, FAAN;
Theresa (Tess) Settergren, MHA, MA, RN-BC;
Mary L. Hook, PhD, RN-BC;
Catherine H. Ivory, PhD, RN-BC
The phenomenon of data rich, information poor in todays electronic health records (EHRs) is
too often the reality for nursing. This article proposes the redesign of nursing documentation to
leverage EHR data and clinical intelligence tools to support evidence-based, personalized nursing
care across the continuum. The principles consider the need to optimize nurses documentation
efficiency while contributing to knowledge generation. The nursing process must be supported
by EHRs through integration of best care practices: seamless workflows that display the right tools,
evidence-based content, and information at the right time for optimal clinical decision making.
Design of EHR documentation must attain a balance that ensures the capture of nursings impact
on safety, quality, highly reliable care, patient engagement, and satisfaction, yet minimizes death
by data entry. In 2014, a group of diverse informatics leaders from practice, academia, and the
vendor community formed to address how best to transform electronic documentation to provide
knowledge at the point of care and to deliver value to front line nurses and nurse leaders. As our
health care system moves toward reimbursement on the basis of quality outcomes and prevention,
the value of nursing data in this business proposition will become a key differentiator for health
care organizations economic success. Key words: clinical decision support, electronic health
record, evidence-based practice, nursing documentation

Author Affiliation: KPIT Care Delivery Business

Information Office, & National Patient Care Services,
Kaiser Permanente, Oakland, California
(Ms OBrien); Healthcare Executive and Nursing
Informatics Pioneer, Atlanta, Georgia (Dr Weaver);
Nursing Informatics, Enterprise Information
Services, Cedars-Sinai Health System, Los Angeles,
California (Ms Settergren); Department of
Knowledge-Based Nursing (NBN), Aurora Health
Care, Milwaukee, Wisconsin (Dr Hook); and
Vanderbilt University School of Nursing, Nashville,
Tennessee (Dr Ivory).
The authors acknowledge the extraordinary contributions of the Nursing Knowledge Big Data Science Workgroup 10 on Transforming Nursing Documentation.
The authors declare no conflict of interest.
Correspondence: Ann OBrien, RN, MSN, 5810
Owens Dr Bldg. F #2019, Pleasanton, CA 94588
(ann.obrien@kp.org).
DOI: 10.1097/NAQ.0000000000000132

HE GOAL set forth by the Institute of

Medicine is that by the year 2020, 90%
of clinical decisions will be supported by accurate, timely, and up-to-date information and
will reflect the best evidence available.1 However, care that is important is often not delivered and care that is delivered is often not
important.2 This is partly because of the failure to apply the evidence that is most effective. The Health Information Technology for
Economic and Clinical Health Act,3 enacted as
part of the American Recovery and Reinvestment Act of 2009, was successful in incentivizing health care organizations to implement
electronic health records (EHRs). As a nation,
the United States is early in the journey of realizing the benefits of digitizing health care.
Although the transition to EHRs was intended
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to promote ubiquitous access to patient information and the delivery of best evidencebased care, the design has increased the documentation burden and decreased the ability
to see the big picture of the patients story,
problems, and goals.
The phenomenon of data rich, information poor in todays EHRs is all too often the
reality for nursing. Despite being the largest
users of health information technology and
the discipline that documents more than any
other group of health professionals in acute
care organizations, nurses receive a negligible amount of knowledge to help inform their
practice. In 2014, a group of diverse informatics leaders from practice, academia, and the
vendor community formed to address how
best to transform electronic documentation to
support highly reliable, evidence-based practice (EBP) and improve knowledge at the
point of care. This article describes the results
of the year-long collaboration (Workgroup 10
from the Nursing Knowledge Big Data Conference at the University of Minnesota): the creation of a set of principles and recommendations for nursing leaders on optimizing EHRs
to improve the processes of care delivery and
to generate actionable information for nursing
care decisions and quality outcomes improvement at the patient, unit, and organizational
level.
The Institute of Medicine recently described the mounting complexity of modern health care, rising costs, and over- and
underdelivery of key services and called for
substantial change.2 The federally funded
Health Information Technology for Economic
and Clinical Health (2009) Act began providing financial incentives in 2009 to support the widescale purchase and adoption of
EHRs and the meaningful use of interoperable data for health information exchange
and the improvement of health outcomes.3
Since that time, the implementation of EHR
systems in acute care hospitals rose significantly from 13% in 2008 to 83% by the end
of 2014.4 In 2014, reports indicated that a
small number (8%) of hospitals implemented
basic EHRs with patient demographics,

problem list, medication list, discharge summary, medication order entry and laboratory,
radiology, and other diagnostic tests result
reporting.4 More (41%) organizations implemented basic systems with clinical notes including basic functionality, physician notes,
and nursing assessments.4 Only 34% of nonfederal acute care hospitals implemented a
comprehensive EHR with basic functionality, clinical notes and computer provider order entry, nursing orders, advance directive,
imaging, and clinical decision support (CDS)
functionality.4 The meaningful use initiative
has largely focused on physician documentation to drive clinical decisions and share data,
with less attention to nursing data or patient
outcomes.
CURRENT STATE OF ELECTRONIC
NURSING DOCUMENTATION
Nursing care and documentation have
been evaluated using a variety of methods.
Time and motion researchers using sampling
methods to describe how medical surgical
nurses spent their time reported the percentage of shift time spent on documentation
ranged from 19% to 35.3%.5,6 Researchers
who surveyed nurses about their perceptions
of documentation processes during the
transition from paper to electronic systems
reported concerns regarding redundancy,
excessive time away from direct patient
care, and the use of overtime for completing
documentation, concerns that did not decrease with transition to electronic systems.7
Evidence-based practice is a core competency for the nursing profession.8,9 Current
EHRs are not designed to guide the delivery
of highly reliable EBP. Much of the data
rich, information poor phenomenon occurs
because each health care organization implements an EHR system without the ability to
leverage lessons learned from organizations
that have gone before them or access a best
practice central repository that holds examples as data sets complete with clinical terms
mapped to standardized terminologies such
as clinical LOINC and SNOMED-CT. Instead,

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each health care organization starts from
scratch. Often, the clinical personnel tapped
to design and build the new clinical system
are nurses, physicians, and health professionals who show an interest but have no formal
education or certification. Thus, system and
workflow builds are commonly a combination of the organizations current state and the
vendors template forms, resulting in a shoe
that fits very poorly. This is a call for action to
identify and improve the problematic areas
of electronic nursing documentation.
Data entry burden
The process of nursing documentation
within EHRs is primarily data entry into discrete fields in flow sheet rows and columns
similar to a spreadsheet. When data entry is
not intrinsically linked with real-time knowledge and context of how the data fit together within the patients story or a potential
problem, nurses feel like data entry clerks.
Regulatory and accreditation requirements increase the documentation burden for nurses
and contribute to data redundancy (eg, manual auditing of pressure ulcers because the
EHR does not collect data in the way needed
for multiple external reporting requirements).
The growing demand for nursing-based documentation has been described as a burden
a word describing something that is carried,
like a load, a duty, or a responsibility, and
perceived as oppressive or worrisome.10,11
The American Medical Informatics Association (AMIA) recently released a set of recommendations for EHRs by 2020, and the first
recommendation was to simplify and speed
documentation to decrease this burden.12
Documentation expectations of nurses continue to rise, yet nurses need and want more
time for interacting with patients and families and coordinating careactions that may
significantly influence patient/family engagement and satisfaction.
System design
Other researchers evaluating perceptions
of EHR implementation reported that percep-

335

tions were less positive after 6 months and

that users may need more time and training
to acclimate to new systems and changes in
workflow.13 Every health care organization
designs and implements its own version of
an EHR, purchasing a system using the software code used at the time of purchase, and
customized based on local perceived needs.
Vendor-based clinical content is either purchased or built by the organization on the basis of best practices from internal end users
or input from external sources. Organizations
are typically responsible for updating content
or purchasing upgrades from the vendor.
Inattention to nursing workflow
Historically, EHR systems have been designed to ensure that organizations are able
to meet existing regulatory reporting and reimbursement requirements. Nursing content
is often conceptualized as though it occurs on
paper with limited considerations about how
it supports nursing-based decision making or
patient engagement. Nurses must remember
where to go next in an EHR, rather than having essential data provided to them at key
decision points in the workflow. Electronic
health record design may increase the workload complexity and decrease time for clinician face-to-face communication. Physiologic
monitors, ventilators, low acuity vital sign machines, anesthesia machines, and other pointof-care devices are rarely fully integrated with
the EHR, requiring nurses to manually enter
electronic device data into the EHR. This manual transcription creates more work that adds
no value to patient care.
Lack of CDS
Efforts to create, standardize, and share effective Clinical Decision Support (CDS) tools
for supporting nurse-based patient care are
limited. Clinical decision support technology should make it easier to operationalize evidence for point-of-care nursing, especially if the tools are positioned within the
workflow.14 The use of EBP or quality bundles by nurses often requires implementation

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and use of tools including checklists, workflow planning, reminders, online resources,
education, and mentoring to ensure consistent use in daily practice.10,15 In addition to
using CDS to support patient care, these tools
are also useful in facilitating oversight and
outcome management. Nurse leaders have a
strategic role in facilitating and regulating the
use of EBP, but nurse managers do not currently monitor guideline adherence as routine
practice.16 Clinical decision supportbased
reports and near real-time dashboards provide
managers with an efficient way to monitor
EHR-derived data and support them in overseeing the care and outcomes on their units.
Effective CDS and data analytics rely on
accurate and complete data entry. Data integrity may be influenced by the heavy burden
of documentation and a limited understanding by individual nurses who may not value
data beyond getting through the day. Limited leader oversight of documentation may
also impact the integrity and limit the value
of the data and reports that are produced.
The availability of nursing-sensitive data in the
clinical data repository for every acute care
hospital suggests that all these data could be
extracted and analyzed to generate sophisticated outcome measurements for evaluating
the nursing contribution to patient outcomes
and testing the effectiveness of nursing interventions using practice-based evidence. Barriers have been identified that limit the use
of these data, including a lack of data standardization and harmonization, differences related to code version control, other local customizations, varied documentation policies,
data quality issues, and interface design.17,18
Data quality may also be influenced by system design and end user performance. Ideally, EHRs should be designed with optimal
usability concepts in mind, including consistency, effective information presentation, naturalness, efficiency, flexibility, and feedback
to support users and prevent errors.19 Many
organizations have not yet found a way to
provide and maintain access to current standards and knowledge sources from inside the
EHR. Access to info buttons or focused evidence summaries is often available from li-

brary sources outside the EHR and requires

an organization subscription for access. It is
difficult to create and maintain access to the
right information at just the right time in the
workflow, personalized to each patient.
Shareability and Comparability
Historically, nursing clinical content in the
EHR has been designed and implemented by
consensus to meet organizational goals, regulatory requirements, or EHR vendor recommendations. Organizational data can be used
to create real-time and retrospective tools for
decision support, quality improvement, research, and administrative decision making,
but the benefits of these data do not easily extend beyond organizational boundaries.
One notable positive example is the sharing of
nursing-sensitive data between venues using
electronic summary reports in benchmarking
on the basis of the specifications and submitting them to external organizations such as
the National Database for Nursing Quality Indicators.
Missing concepts
National efforts are in progress to evaluate granular nursing content across organizations and define and map content to standardized clinical terminologies, including LOINC
and SNOMED-CT, the de facto terminologies
promulgated by Centers for Medicare and
Medicaid Services and Office of the National
Coordinator for Health Information Technology. It must be recognized that standardized terminologies may not contain all concepts reflecting nursing care, and requests
must be frequently submitted to ensure that
terminologies are robust enough to capture
nursings contribution to quality, safety, and
affordability.
VISION
The Institute of Medicine encourages the
adoption of a new vision for the health care
system, providing Americans with superior
care at lower cost.20 The ideal future state
of the new learning health care system

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involves generating and applying the best
evidence for the collaborative health care
choices for each patient and provider; driving the process of discovery as a natural outgrowth of patient care; and ensuring innovation, quality, safety, and value in health
care.20 The EHR for this new system must
be patient-centered, accessible, transparent,
and interoperable and support or enable EBP,
performance improvement, and interprofessional team-based care for better patient outcomes. Workgroup members embraced the
new vision and identified that the ideal state
would have the following characteristics:
Documentation is simple and fast with
a focus on relevant content with minimal redundancy, capturing the essence
of care.
The EHR captures the needs, wishes,
and preferences of the patient/family and
drives and coordinates the plan of care;
patients are codesigners of the plan.
A source is identified to serve as a central repository for best practice clinical
forms, standardized assessments and interventions, evidence-based bundles, and
CDS rules. This library of resources would
be vendor-neutral and freely available to
all health care organizations.
Nurses and interprofessional colleagues
are engaged in EHR design and build content and CDS to support surveillance, audit, outcomes measurement, patient engagement, and research.
Data are standardized, actionable, and
interoperable between inpatient, ambulatory, skilled nursing facility, home
care, and community care services and
connect disparate care episodes, integrating care settings and community
providers with patients and patientgenerated health data.
Biomedical devices are integrated to support accurate and timely data capture and
use.
Clinicians have access to accurate, timely,
relevant clinical information from multiple sources with well-designed, efficient,
and standardized workflows and CDS

337

tools that support the nursing process

and evidence-based care.
Nurses and nurse leader decisions are
supported by dashboards that include
EHR-generated analytics for operations,
patient and program outcomes, benchmarking, and other needs and relevant
data from the broader social environment.
The workgroup developed these recommendations informed by the HIMSS
CNO/CNIO Vendor Roundtable, Big Data
Principles Workgroup and the AMIA Nursing
Informatics Scholarship Initiatives, as well
as AMIAs EHR 2020 Task Force report.12,21
For optimal results, system designs must be
simple, effective, and efficient, and produce
accurate and usable data for extraction. This
process can be enabled by ensuring that nursing assessment and interventions are mapped
to terminology standards to enable sharable,
comparable nursing data. It is essential to
create mechanisms to ensure and validate
the integrity of EHR data. The transition to
predictive analytics requires nursing data
that are accurate, complete, and timely. The
business case and road map for these recommendations are defined in the JASON Report
commissioned by the office of the national
coordinator, in which the task force stipulates
that these standards are needed to efficiently
extract data, support innovation with 21st
century information technology tools, and
interact across multiple commercial EHRs.22
Another strategic recommendation is for
nurse leaders to be knowledgeable of and to
actively engage at their local organizations in
support of adopting SNOMED-CT and Clinical LOINC as data standards for all nursing
clinical data. These 2 terminology standards
have been endorsed by nursing informatics
leaders in HIMSS and AMIA and serve as the
international standards across the Commonwealth countries and continental Europe as
well.23 Encoding of nursing data in a standard
way means that nursing data generated from
care delivery would be available to nursing for
generating reports on patient outcomes from
the clinician level to the unit, department, or

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organization level. In addition, clinical data

could be aggregated with other data from
disparate sources, such as finance and
human resources, to answer questions related to costs, staffing levels and outcomes,
and comparisons between organizations. This
single step of achieving standardized, coded
nursing data is the biggest mover of the value
proposition for front line nurses and nurse
executives. For the first time, nurses would
be able to access their own clinical quality
metrics and compare them against benchmark peer groups, as well as trend them over
time. Nurse executives would have the data to
discover best practices, outcomes, and most
cost-effective care delivery. Coded data enable
aggregation and querying to answer clinical
questions and perform comparisons over time
or across organizations. It is the basic building
block of delivering power over its business
and practice into the hands of nursing. The
task of nurse executives is to build an informatics team that has extensive knowledge in
mapping nursing concepts to Clinical LOINC
and SNOMED CT.
In closing, 2 important health information
technology policy conversations are happening in the halls of Congress as this article is going to press that carry important implications
and opportunities for improving the value of
health information technology for nursing and

patients. The first urges a refocus on regulatory mandates for quality and safety measures
that use data generated from actual care delivery and require no extraneous work on the
part of health professionals. The second initiative pertains to requiring EHR vendors to use
pubic standards-based Application Programming Interfaces (API) and data standards to
be more open to innovators, developers, researchers, and patients.
SUMMARY
The current state of EHRs has increased the
burden of documentation and provided limited support for nurses and nurse leaders to
identify individual needs of patients and deliver personalized, highly reliable, evidencebased, efficient patient care. Nurse leaders
and their nursing informatics partners must
be engaged at all levels to ensure that the redesign is interdisciplinary, integrates best evidence with seamless workflows, includes the
capture of coded nursing data, and leverages
CDS tools to support patient safety, quality
outcomes, and nursing satisfaction. Guidance
for nurse leaders and managers is proposed
with a focus on key strategic differentiators
and investments needed in building an informatics team with the skills to deliver optimum
value for nursing.

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